This course explores the concepts of critical thinking, clinical reasoning, and clinical judgment and their relationship to the new graduate nurse transitioning to practice. It also reviews strategies that health care organizations can use to bridge the education-to-practice gap and foster the development of clinical judgment.
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event errors, using technology, and overcoming the powerful influence of personal views; Alfaro-Lefevre, 2019)
In 1985, Patricia Benner first noted that critical thinking was based on attitudes and skills relative to logic, rationality, and reasoning (Benner et al., 2009). A person’s knowledge, skills, and attitudes (KSAs) drive critical thinking. The Quality and Safety Education for Nurses (n.d.) competencies, which focus on positive patient outcomes, highlight the importance of KSAs in nursing education and for new nurses as they transition to practice. Nurses working in various clinical settings will encounter numerous opportunities for critical thinking, including:
- problem-solving, decision-making, or judgment
- patient or caregiver safety
- diagnostic reasoning (understanding and applying the nursing process)
- delivering patient-centered care
- applying moral and ethical reasoning
- applying EBP to deliver care
- using electronic medical data
- personal self-improvement, stress management, or health promotion
- improving patient outcomes and care delivery systems through quality improvement (Alfaro-Lefevre, 2019)
Given the complexity of the clinical environment, memorization-style thinking is insufficient to equip nurses with the skills to sort, organize, and interpret relevant information for effective and safe patient care. Instead, nurses must work with a broad foundational knowledge base to individualize patient care across various clinical settings. Nursing education provides the foundation for critical thinking through experiences, reflection, communication, and observations. Then, clinical experience further develops critical thinking skills for new graduate nurses. Nurses encounter critical thinking and reflection opportunities when interacting with patients during times of health and illness in the clinical setting. Nurses need to use the knowledge obtained in nursing school and clinical practice to create knowledge connections that foster critical thinking. Clinical reasoning occurs when nurses apply critical thinking skills, integrating theoretical knowledge with actual clinical experience. Nurses who are inquisitive and actively involved in their learning are more likely to foster sound clinical judgment successfully (refer to Table 1; Craven et al., 2021).
Table 1
Characteristics That Foster Critical Thinking and Clinical Reasoning
Critical Thinking | Clinical Reasoning |
- Effective communicator
- Honest and ethical
- Insightful and analytical
- Flexible and improvement-oriented
- Self-aware, responsible, and accepting of accountability
- Inquisitive and looking for the rationale behind actions
- Intuitive and logical
- Reflective and self-correcting
- Resilient and confident
- Prudent with the delivery of care
- Sensitive to diversity, open-minded and fair, showing tolerance for others
| - Applies a cyclical process involving cue acquisition and analysis to take appropriate actions within the required time to facilitate positive outcomes
- Uses formal and informal thinking strategies to gather and analyze patient information
- Evaluates the significance of gathered data and weighs alternative actions
- Can analyze, use logic, seek information, discriminate, apply standards, predict, and apply the knowledge
- Effective communication skills, along with an appropriate educational level, knowledge, and ability to think critically, along with a familiarity with the environment and context of care
|
(ANA, 2024; Craven et al., 2021; Wolters Kluwer, 2020)
Clinical judgment requires that critical thinking and clinical reasoning occur in care delivery. Tanner first described this concept in 2006 as “an interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” (p. 204). Tanner further develops a clinical judgment model from over 30 years of research synthesis, incorporating four aspects of clinical judgment: noticing, interpreting, responding, and reflecting (Tanner, 2006). According to this model, a nurse’s judgment in the clinical setting involves the following:
- a grasp of the clinical situation at hand and an awareness of it (noticing)
- interpreting the situation and determining how to respond (interpreting)
- deciding on an appropriate course of action (responding)
- attending to the patient’s responses to the action and assessing the situation (reflecting)
- reviewing the outcomes of the action while focusing on the appropriateness of all the preceding actions (reflecting; Benner et al., 2009; Billings, 2019; Cadavero & Oermann, 2020; Tanner, 2006)
Impact on Patient Outcomes
The quality of patient care depends on nurses who are prepared to recognize their needs and respond accordingly. Nursing judgment directly impacts the ability to apply EBP and to react to changes in the patient’s condition. Hospitals have acknowledged the lack of student preparedness for years and implemented extended orientations, preceptorships, mentoring programs, and nurse residency programs to bridge the gap between the education and practice settings. The transition from novice nurse to an advanced beginner is filled with insecurities, a lack of experience, and a deficit of clinical judgment. Both patients and medical facilities benefit from nurses who can demonstrate competent clinical judgment. Lasater and colleagues (2015) found that only 13% of preceptors believed novice nurses could establish priorities and demonstrate safe nursing care. High-quality patient care depends on the nurse’s competence and application of clinical judgment (Lasater et al., 2015). The National Council of State Boards of Nursing targets optimal outcomes for patients, nurses, and clinical organizations. Nurses should enter practice with the ability to make appropriate clinical decisions through clinical judgment (National Council on State Boards of Nursing [NCSBN], n.d.-b).
Despite organizational strategies to improve the safety and efficacy of patient care, preventable health care errors are the third leading cause of death in the United States. New graduate nurses represent 6% of the nursing workforce and often enter practice with a basic skillset and limited experience with actual patient scenarios, which are essential for developing clinical judgment. Treiber and Jones (2018) conducted a mixed-methods study to understand individual- and system-level factors surrounding medication errors by new graduate nurses. They found that 55% of new graduate nurses admit to making an error within their first five years of clinical practice (Treiber & Jones, 2018). Dynan and Smith (2022) investigated the relationship between hospital spending on continuing nurse education and staff on nurse-sensitive, patient-safety outcomes, including pressure ulcers, central venous catheter-related bloodstream infections, and deep vein thrombosis (DVT). The researchers found that a one standard deviation increase in nursing education was associated with a 16% reduction in catheter-related bloodstream infection and a 5% reduction in DVTs (Dynan & Smith, 2022). New graduate nurses continue to have higher rates of errors, failure to rescue, and missed care than experienced nurses, resulting in preventable patient morbidity and mortality (Jessee, 2021).
Developing Clinical Judgment
New graduate nurses may take several years to develop clinical competence and sound clinical judgment. Research indicates that regardless of education, experience is the most significant indicator of clinical judgment, particularly within specialty care areas such as intensive care or obstetrics (OB): nurses need between three and six years of experience to demonstrate the highest levels of clinical judgment. Experienced nurses have an internalized ability to assess, apply knowledge and intuition, provide intentional thought in a situation, and collaborate with their peers and health care team to deliver safe and effective care. Nursing leaders must find ways to foster the development of clinical judgment in new graduate nurses. Nursing education is crucial in preparing new nurses to utilize the nursing process and exhibit clinical judgment (Cadavero & Oermann, 2020; Tanner, 2006; Wolters Kluwer, 2020).
In response to the information that new graduate nurses were not meeting the minimum expectations for safe and effective care upon entry into practice, the NCSBN generated a task model to measure clinical judgment. This model is used to frame the teaching and evaluation of the complex skill of clinical judgment. The NCSBN further developed test items to evaluate prelicensure nursing students’ ability to make safe and accurate clinical judgments. These test items were added to the National Council Licensure Examination (NCLEX) test plan during the 2023 testing cycle. Before developing these test items, they developed the NCSBN clinical judgment measurement model (NCJMM). Researchers from the NCSBN created the NCJMM as a “framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination” (NCSBN, n.d.-a, para. 1). This model does not redefine clinical judgment but gives the NCSBN and nurse educators a method for measuring and deriving inferences around clinical judgment and the ability of entry-level nurses to make decisions that are safe and effective for positive patient outcomes. Six steps within this model define the clinical judgment process; refer to Table 2 for the steps and associated tasks (Billings, 2019; Dickison et al., 2019; NCSBN, n.d.-a).
Table 2
Steps in the Clinical Judgment Process and Associated Tasks
Step | Tasks |
1. Recognize cues | - Assess the patient
- Review patient chart information
- Consider the patient’s views and desires
- Differentiate relevant and irrelevant data
|
2. Analyze cues | - Determine patterns
- Connect the cues
- Discern concerning information
- Decide if more information is needed
|
3. Prioritize a hypothesis | - Combine or cluster the information
- Focus on the possibilities
- Decide on prioritizations
- Determine the risk of action or lack of action
- Give evidence for the hypothesis
|
4. Generate solutions | - Consider several possible care options
- Connect an understanding of the patient’s needs to possible courses of action
|
5. Take action | - Implement the plan of action
- Perform the skill or procedure
- Administer medication
- Collaborate with the health care team
- Teach the patient or their family
- Practice ethical and legal behaviors
|
6. Evaluate outcomes | - Determine if the desired outcomes were achieved
- Determine if the actions were effective
|
(Billings, 2019; Dickison et al., 2019; NCSBN, n.d.-a; Uworld Nursing, 2025)
Strategies to Foster Clinical Judgment in New Graduate Nurses
The nursing profession has evolved significantly over the last few decades, shifting from task completion to skilled nursing care. Care provided by professional nurses and nonprofessional caregivers differs, with the professional nurse utilizing the nursing process to establish sound clinical judgment. Given the numerous challenges nurses face in the clinical environment (i.e., rapidly changing situations, high patient-to-nurse ratios, high acuity, and the prevalence of chronic conditions), critical thinking and clinical judgment are considered essential skills. Health care organizations must consider various strategies to support the development of clinical competence and clinical judgment in new nurses, including addressing the education-to-practice gap, mentoring, simulation-based learning, and new graduate nurse residency (NGNR) programs (Daneshfar & Moonaghi, 2025; Murray et al., 2019; Treiber & Jones, 2018; Wolters Kluwer, 2025).
Education-to-Practice Gap
The widening education-to-practice gap has challenged health care organizations to identify strategies to foster clinical judgment in nurses. The education of nurses has traditionally focused on classroom-based learning, supplemented with clinical experiences. However, research has suggested that these singular strategies are ineffective in preparing nurses for clinical practice. More specifically, academic programs often focus solely on the NCLEX pass rates as the single measure of success. Health care organizations expect new graduate nurses to join the workforce highly competent and prepared to function in the complex health care environment. However, the reality is that many nurses do not meet the expectations for entry-level clinical judgment, potentially resulting in adverse outcomes. Health care organizations are tasked with identifying ways to eliminate the education-to-practice gap related to new graduate nurses’ clinical judgment and competence. Even though there has been significant progress in defining the role of the professional nurse, a knowledge barrier still exists regarding understanding clinical judgment in nursing. Research has shown that nurses have a primary and simplistic understanding of clinical judgment in nursing. More specifically, many nurses equated clinical judgment with good nursing care. Therefore, the first step toward improving nurse competence and clinical judgment should be establishing and defining the relationship between a sound knowledge base, reasoning, and critical thinking skills, as well as their impact on effective clinical decision-making (Connor et al., 2022; Kavanagh & Sharpnack, 2021; Kavanagh & Szweda, 2017).
Mentoring
Mentoring or clinical role modeling is another strategy that can help foster competence and clinical judgment in new nurses. As new nurses transition from student to practicing nurse, they often experience a phenomenon known as transition shock. Transition shock is a nonlinear movement through professional role transition that encompasses developmental, intellectual, skill, and role-relationship changes. Three stages of transition occur over 12 months, including doing, being, and knowing. Each stage is defined by psychological development that influences their skill development. During the early months of practice, new nurses find their idealistic expectations disparate from reality. Due to their limited clinical experience, new nurses often experience stress and anxiety, which is part of transition shock. Feelings of self-doubt and a lack of confidence can hinder the development of clinical judgment, potentially leading to adverse patient outcomes. Clinical mentors or role models can be critical in transitioning new nurses to practice. Successful role transitions can occur when new nurses work in a safe and supportive environment. Health care organizations must prioritize new nurse transition to practice by ensuring that effective mentors and role models are in place. Given the challenges in the clinical environment, including staffing shortages and insufficient role models, clinical judgment can be negatively impacted. Nursing leadership should employ methods to enhance communication and teamwork in their units to foster a safe and supportive environment. Positive interpersonal relationships and mentoring facilitate a trusting clinical environment that supports knowledge sharing, critical thinking, and clinical judgment (Gularte-Rinaldo et al., 2022; Kerns & Wedgeworth, 2025; Murray et al., 2019). Powers and colleagues (2019) found that nurse preceptors were critical to a successful transition to practice for new nurses. Effective nurse preceptors can build confidence, decrease anxiety, and foster clinical judgment.
NGNR Programs and Simulation-Based Training
In the Future of Nursing report, the Institute of Medicine (IOM) called for a foundational shift in nursing education and transition to practice. Research has supported the existence of the education-to-practice gap that leaves new graduate nurses with limited clinical experience to foster sound clinical judgment. NGNR programs are a newly developed model that health care organizations use to promote clinical skill acquisition, build confidence and competence, and encourage role socialization. These programs offer a structured transition-to-practice model that incorporates role modeling, communication, teamwork, skill building, simulation, and other opportunities for new graduate nurses to feel safe and supported in their transition to practice (Wolters Kluwer, 2025). Rush and colleagues (2019) evaluated the best practices of NGNR programs and found that these programs support nurse retention, satisfaction, and perceived competence. More specifically, confidence and competence were crucial aspects of NGNR programs, with nurses self-reporting increased knowledge, skill acquisition, communication, and clinical decision-making during challenging situations. When self-perceived confidence and competence are high, nurses are more likely to improve their critical thinking and clinical judgment (Rush et al., 2019). In a qualitative study evaluating new graduate nurses’ perception of their evolving clinical reasoning and judgment, Wright and Scardaville (2021) found that reflective journaling was a key component of NGNR programs. The researchers concluded that reflective journaling is vital for the self-analysis of clinical decision-making for new nurses, which can foster clinical judgment (Wright & Scardaville, 2021).
High-quality simulation-based training has been supported in the literature as an intervention to develop clinical judgment in prelicensure nursing students. Many health care organizations have begun to use simulation-based training for new nurses during their transition to clinical practice. This strategy allows health care leadership to provide experiential learning opportunities in a controlled, safe learning environment. Given that many new nurses are underprepared to manage high-acuity situations and demonstrate poor clinical judgment, simulation opportunities can help fill this gap. High-fidelity simulation (HFS) utilizes computerized software within the manikin to mimic conditions that would occur in a real clinical experience. During nursing school, simulation-based training is often focused on skill acquisition. Simulation-based training during the transition to practice can be used for high-risk, low-frequency scenarios that allow new nurses to experience these clinical situations in a safe environment with guided mentoring and reflection opportunities. Simulation fosters teamwork, communication, and collaboration, all predictors of sound clinical judgment (Daneshfar & Moonaghi, 2025; Tyndall, 2022). In a quasi-experimental study, Kim and colleagues (2018) evaluated the effect of simulation-based handoff training on clinical competence and judgment for new graduate nurses. They found that new graduate nurses who received simulation-based training had higher clinical competence regarding handovers and clinical judgment than those who received peer-learning training. Health care organizations and nursing leadership should consider incorporating simulation-based training for nurses to help foster clinical competence and judgment (Daneshfar & Moonaghi, 2025; Kim et al., 2018; Tyndall, 2022).
References
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